SPECIAL REPORT: Re-thinking ‘Extended Care’ units in State Hospital Centers


This presentation is independent of the Office of Mental Health (OMH), the Department of Health (DOH), and other federal commissions that hire researchers on trends in funding and insurance reimbursement. At the crux of it, both sides of the community versus inpatient debate realize the risks and benefits. Patients must be continually evaluated to determine if the treatment given in a state hospital can be safely provided in community settings. A report written by NASMHPD states that in the year 2012 alone, over 40000 patients across the US were hospital networks will just be relics, anachronistic holdovers of the sins of psychiatry. Where the last great psychiatric cathedrals now stand is a carefully laid out and organized system of hospitals. These hospitals continue to symbolize the harm done to an entire population of mental health patients, who were then described as ‘sick’ or ‘mad’. The institutions included treatment rooms in which ‘medical interventionists forced medication, shock treatment and lobotomies upon patients. Even more insidious and covert forms of treatment were also administered, particularly by the most recent abuser, the pharmaceutical companies. This sets the stage for a new level of state psychiatric mistreatment as the 21st century unfolded.

Today, the legacy of state psychiatric centers in the US is being challenged by former patients, psychiatric survivors, and peers, whose goal is to liberate medicine from psychiatry. Still, research funded and disseminated by organizations like the Treatment Advocacy Center (TAC) and other reports which inform the emerging trends in state funding continues to be off the mark. Indeed, forced treatment and assisted outpatient care need to be continuously re-evaluated which could benefit from release from psychiatric hold and deferred recovery due to problems rooted in access and connectivity to care. However, the reports generated by TAC and other advocacy organizations which put ‘treatment’ ahead of the needs and voices of the consumers truly requires more careful consideration on the part of lawmakers and stakeholders making decisions on how day-to-day operations are carried out by practitioners in state-run units than simply blanket appraisal and adoption of their recommendations. These are recommendations that continue to ignore the reality of life on the unit, and condemnation to extended and ‘ongoing’ treatment without consent, and, even worse, effectiveness in avoiding rehospitalization and certainly not expedited discharge to the community.

To fully integrate services and consumers in the network of already available mental health programs, remaining patients in the long-term state psychiatric centers must be discharged and released from the eternal holding pattern to ultimately integrate and help consumers gain access to community resources, and most importantly, to allow them to live among other people outside the gates of the institute on. Therefore, Phase I of the WCT manual for community access will target the release, discharge, and reintegration of patients into the community. Later phases and future the research will target the establishment of reliable systems in which chronic and high-risk patients will have reliable access to services and programmes that will benefit this group in lieu of hospitalization
(Gagani, Gemao, Relojo, & Pilao, 2016).

Access to outpatient services

This plan begins theoretically at the level of local and state governments and municipalities that govern the regulation of mental health treatment: the state mental health authorities, the National Association of State Mental Health Program Directors (NASMHPD), in collaboration with federal agencies, must approve funding for WCTs to infiltrate access state psychiatric hospital operations and systems at all levels that impact discharge planning and community re-integration. In theory, each freestanding unit in all state hospitals will work side-by-side with its assigned WCTs. Social workers, psychiatrists and all inpatient staff charged with the successful discharge of its patients must partner with the WCTs until the final discharge from the hospital in which the final patient re-enters the community. The crux of Phase I is the funding needed to staff the WCTs across the states. Each team will serve as an interdisciplinary reflection of the treatment gaps identified at each hospital’s locale. This meant that prior to each WCT beginning its work in a unit, the hospital will send a memorandum of requirements to the Office of Mental Health, which will inform the make-up of the teams assigned to each hospital and community. Thus, needs related to transportation and rural concerns will be managed by WCTs specializing in the needs of rural communities and their mental health systems. More urban-based communities with complex spatial access issues will be staffed with workers adept at handling the mental health concerns of patients in an urban setting.

The WCTs is a multidisciplinary, mobile field unit, and treatment team operated and regulated by state mental health authorities. Each team will be trained to target chronic diagnoses, relapse prevention, and offer treatment in a flexible, organic, person-centered approach. While the WCT and assertive community treatment (ACT) are similar in composition, in keeping with evidence-based practices (EBP), the potential for the WCT’s positive impact on clients and, in turn, the likelihood for good outcomes could not be more radically different. ACT team meets with clients for a minimum of 15 minutes of face-to-face contact to be able to bill and consider the home visit a session. While sessions usually run longer, as patients typically have errands or complex case management issues or need transportation to medical appointments to and from treatment, or any number of complex case management issues the WCT clinician or peer needs to address in session, 15 minutes alone is simply not enough for patients discharged from state hospital step down unites. In keeping with this premise, the completion of tasks patients typically request help with or just require the attention of the worker to go on and on. There is a laundry list of needs patients have after discharge from the highest level of care. It is immense, overwhelming for clients still symptomatic and clinically determined to be safe, stable, and ready for re-entry into the community.

Integrating into the community is a challenge without a mental health disorder which distorts, complicates, and makes the vast obstacles ahead seem almost insurmountable. At the root of it, these are not clinical issues, but complex case management issues i.e., connection to medical providers, food shopping, obtaining hygiene, and other household products due to transportation issues. Many clients surrender their driver’s licenses prior to admission to the hospital due to legal, or mishap and unfortunate circumstances. In many cases, due to high caseloads, productivity requirements, and other extraneous non-clinical issues, session times are limited, cut short, or only begin to address these serious problems patients struggle with upon re-integrating into the community. So, upon initial integration to the community, WCT sessions will be longer the length to bill for sessions under Article Zero and count the contact as a required visit. Similarly, instead of a minimum of six contacts a month with each client on the census, required monthly contacts should also increase. Simply put, for WCTs to consider the patient enrolled under the care of WCT, sessions should be doubled in length for clinicians and peers to be effective for the upward mobility of a patient’s recovery.


The planning involved for both the ward closure teams and the existent treatment teams in the units surpasses the assessment of the composition of the community. Indeed, ward closure teams will be required to have a full understanding of local existing services in the community and will work side-by-side with treatment teams in the units to identify issues foreseen prior to each discharge. Hence, issues of adherence will be measured against connectivity issues in the communities’ existing healthcare networks. Other issues, such as medical comorbidities, will necessitate ward closure teams to acquire a full understanding of existing health networks that serve clients with complex medical and psychiatric issues and other complex case management services, which freestanding clinics do not traditionally provide. Simply put, WCTs can supply case management services to users dependent on the system of care after discharge from the hospital, and its vast and complicated services. Given the freedom to complete more case management services, while also providing clinical services, and be the primary point person in consumer care, time-consuming and high impact complex care management tasks can be completed without incident, including certification and recertification of benefits to continue all of the medical necessities are completed so services run without interruption.

Under Article Zero, the incentives to learn, either through continuing education, but either way, certified in new treatment modalities which are proven through evidence-based studies to improve the prognosis of chronic patients being discharged from long-term care settings i.e., state hospitals are not just to experience better outcomes for clients, but also build a track record as a practitioner. So, all new and existing treatment teams on the state hospital grounds as well as treating patients discharged from a state-level facility will be required to be versed and certified in peer-supported open dialogue (POD); and cognitive behavioural therapy (CBT) targeting psychosis, delusional disorders, and a range of diagnostic interventions commonly associated with patients with chronic disorders. Thus, diagnostic and public policy stakeholders of health and medicine all suggest ACT or PACT (Programs of Assertive Community Treatment) in some states should be repurposed and selected as the best available discharge plan after graduation from a step-down unit in a state hospital. In addition to being a mobile unit, care managers, and discharge planners for high-risk patients will benefit by beginning treatment within the walls of the hospital, something ACT teams are limited to do, and according to state regulations and programme guides, in New York State, and can only perform tow ‘hospital visits’ per month to bill for, and maintain the client on the team’s census. Thus, in addition to being more versed new EBP, WCTs benefit from operating the same physiological space as patients treatment team on the unit, a length of time which can be determined state to state, but always able to fully operate at two polarities, the highest level of care and conversely, the least restrictive environment possible, that is, within the community. Upon discharge, patients still under the care of extended care, will step down to transitional care units, sometimes called TCU, WCTs can begin their fieldwork inside the hospital unit, and plan to one day complete home visits upon their patients’ successful discharge from the step-down units or TCU inside the facility of care of ACT or PACT, and, under the provision of services for an undetermined, if necessary, permanent team of patients determined by individual state mental health authorities to require its care which is already prescribed by ACT or PACT guidelines for practice across states (Stein & Santos, 1998) and in A Manual for PACT Start-Up (Allness & Knoedler, 1999).

Phase I

Prior to discharge from the hospital, and incongruence with regulations in several states (New York, New Jersey, Connecticut, etc.), discharge planners across all state facilities will have the responsibility of preparing all clinical treatment plans up for review for immediate step down to a lower-level of care. In doing so, the timetable will be set; while in some states, plans are reviewed every six months, others three, regardless of the lifespan of the plan, personnel in the hospital documenting the transition of patients to the community. Thus, discharge planners will begin to put paperwork into place which will follow clients’ records to the treatment teams in the community which will continue care upon re-integration. This means, across longer-term care units, state hospitals will internally reconfigure their units, to prepare for the large volume of clients discharged from the facility. Without question, this will in turn serve remaining patients well who are mandated by the court, and largely the criminally insane. This subgroup of the state hospital system, according to reports written by NASMHPD, are mostly forensic patients, not including sex offenders, which make up a fraction of the entire state mental health system census. I am suggesting by emptying out and closing down long-term units containing non-violent mentally ill patients, all remaining units will be more likely to be less crowded, better staffed with additional funding now less spread across fewer units. This has proven to reduce the likelihood of conflict and reduce safety issues on the unit in which clients who are extremely agitated react, or act out against their peers and other patients.

When this plan goes into effect, all patients will less likely be exposed to violence. With more money to go around, new spaces and units with a lower census, for a more personalized, person-centered, and safer environment will blossom at the state level. The last segment of Phase I is the expansion of state-level step-down units. In various states, including many of the Northeast, Midwest, and West Coast of the US, step-down units are too frequently used to transition patients back to the community. In many state facilities, including GBHC (Greater Binghamton Hospital Center), RPC (Rockland State Psychiatric Center), and several other state hospitals, only one or two transitional units exist. In theory, all patients in extended care and long-term care units will be transferred to the transitional units available in the facility. Upon the patients’ treatment plan, all new plans requiring an update, will in turn determine the potential date patients are transferred from long-term units to TCU. This is the spark that will light the fire that signals to the inpatient treatment team that new patients now require the attention of hospital staff to determine the long- and short-term planning necessary to begin to successfully discharge patients from long-term units to a lower level of care. This lower level of care, specifically the transitional units available in the facility, will then prepare themselves for new admissions internally transferred from all remaining long-term units. Should, give an analysis of the volume of patients being transferred internally, and ultimately discharged from the transitional unit to the community, it is recommended that the immediate allocation of funding to the creation and expansion of transitional step-down units.

Phase II

To achieve the desired goal, the next major step is implementing Phase II which begins just after the assignment of WCTs to respective communities and state psychiatric centres. At this point in the plan, WCTs of new hired personnel, and even those transferred internally, composed of staff from units armed out and closed down after the facilities reconfigure their census and disbursement of the hospitals’ population, patients’ needs prior to, and after discharge. These WCTs will target, and be staffed by people who are able to target and specialise in specific diagnoses and be prepared for less than promising patient prognosis. Upon gaining access to inpatient services, hospital operations will begin working side-by-side with existing hospital staff. Teams will identify all remaining concerns for patients prior to discharge. This will be a process in which patients will work voluntarily with newly instated WCTs and contract to work with treatment teams in the community earmarked for their care at post-discharge.

Thus, all services will be matched with the needs identified by both the long-term and longstanding clinicians assigned to each unit and patient, as well as the newly commissioned closure teams to achieve the primary goal, which is complete access and the integration of all state hospital patients still in long-term care back into the community and the end of institutionalisation forever. To achieve this aim, the plan and each of its phases require not only community support, but also support from stakeholders regarding mental health and public policies, and also the shared goal of creating a society without walls or restrictive barriers for chronic and long-term mental health conditions who are typically assessed and slated for long-term, ongoing, round-the-clock care that a state institution provides. Thus, the vision and scope of this proposed plan and the prospective teams charged with implementing the final solution and ending the era of neo-institutionalization is clear: full community access to and the integration of all community mental health programs as well as the elimination of a level of care that is both dated and obsolete in the context of the full meaning of deinstitutionalization.

Phase III

Studies continue to evidence the positive trend which suggests people, regardless of their precipitating reason for admission to the hospital, who are supported in their discharge from long-term units, eventually transitioned to a lower level of care without incident and provided access to community resources and mental health treatment are much more likely to succeed in the community than patients either clumsily discharged or without adequate planning. Thus, this three-phase plan lays out a comprehensive third phase. In keeping with the assumption, ACT teams continue to furthermore and more empirical evidence of treating the most chronic and at most imminent risk of self-harm or harm to others. WCTs will ultimately prepare their existing census for discharge to ACT teams, the highest level of outpatient care, and the most effective evidence-based modality across the US for treating this population. Therefore, since ACT teams are already existent everywhere a potential patient is awaiting discharge from a TCU in a corresponding state hospital, these ACT teams will absorb the majority of patients discharged from the WCT. The transition of patients to their assigned WCTs will be synchronized, time and documented similarly to ACT treatment planning. Without recreating the wheel for documentation in the field, WCTs will follow the freewheeling, liberal documenting style and manner of capturing the patients’ clinical picture in the most representative and appropriate outpatient service. Since all outpatient mental health services are ultimately tied to coding and congruent billing, WCTs will follow the coding of ACT services. Therefore, the creation of new medical billing questions does not interfere with the speed and necessity of discharge. Thus, ACT teams will be able to replicate the practices and treatment of WCTs, and the continuum of care will be intact from the moment the patient is discharged from the state hospital and fully transitioned back to the community, without anyone falling through the cracks due to insurance, poor planning, or inadequate services after discharge from the hospital.

The end of neo-institutionalization

Mental health is a community of public health needs and after implementing the proposed plan, the fallacies and misnomers of the old system will never again point towards institutionalizing people and sending the ‘problem’ patients to the long-term care units far from the community and its resources. Access to services must be provided and new pathways must be engendered so that consumers can gain access to the many lines of care already provided by the systems of care in New York State and by all regulatory bodies with a vested interest in mental health treatment. Neo-institutionalisation is complex and insidious, and it must end. Therefore, the focus of the ward closure operations manual is threefold. The first phase of operations targets the state psychiatric centers based on a global assessment of outlying communities and on the express needs of the consumers being discharged. The second phase targets the overhaul of treatment silos and installations already in place in the community that needs more integrated access for consumers. Without question, the resources already exist in the community, and this document proposes how to reconfigure existing structures that provide mental health treatment to serve patients. The success of Phase II depends on the elimination of freestanding treatment silos. This means that all treatment programs that discriminate and choose to openly serve only subgroups or ‘high-functioning patients will be given a mandate by the Office of Mental Health to broaden their scope of services, or they will be subject to a loss of licensing and funding. An example of a programme that only serves a small niche of ‘qualified’ patients includes outpatient settings that refuse to accept state-sponsored insurance for patients who are disabled and reliant on Medicaid and other service dollars. Conversely, treatment centers that offer services to all patients or that are cited for restructuring and successfully reconfiguring their clinics, group practices, and day treatment centers will be awarded funding to commit to on-site projects and community outreach projects to further extend services to the community.

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